Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. To bring this vision of the future of primary care closer to reality, the Institute of Medicine (IOM) appointed an expert committee to carry out a two-year study intended to address the opportunities for and challenges of reorienting health care in the United States. The above definition (published in the committee's interim report in 1994) guided its deliberations and its consideration of the conclusions and recommendations offered in the main part of this report (see Box S-1). Specifically, the report
- gives a clear definition of the function of primary care that can guide public and private actions to improve health care;
- encourages certain organizational arrangements for health care, built on a foundation of strong primary care, that will facilitate the coordination of the full array of services that are essential for maintaining and improving the health status of patients;
- argues for development and dissemination of improved information systems and quality assurance programs for primary care;
- advocates development and sustained support of means to make primary care available to all Americans, regardless of economic status, geographic location, or language and cultural differences;
- suggests financing mechanisms that encourage good primary care rather than episodic interventions late in the disease process;
- encourages support for training of a primary care workforce, sufficient in numbers to meet the needs for primary care, equipped with the skills and competencies that match the function as the committee has defined it, and prepared to work in the context of a team that includes primary care physicians, nurse practitioners, physician assistants, community health workers, and other health professionals;
- favors enhancement of the knowledge base for primary care based on clinical and health services research; and
- speaks to the development of primary care as a continually improving system in an era of rapid change through program evaluations, dissemination of innovations, and continued education of the clinician and patient.
The chapters of this report constitute a road map for reaching the committee's goals, as reflected in five assumptions. First, primary care is the logical foundation of an effective health care system because primary care can address the large majority of the health problems present in the population. Second, primary care is essential to achieving the objectives that together constitute value in health care—quality of care (including achievement of desired health outcomes), patient satisfaction, and efficient use of resources. Third, personal interactions that include trust and partnership between patients and clinicians are central to primary care. Fourth, primary care is an important instrument for achieving stronger emphasis on (a) health promotion and disease prevention and (b) care of the chronically ill, especially among the elderly with multiple problems. Fifth, the trend toward integrated health care systems in a managed care environment will continue and will provide both opportunities and challenges for primary care.
Definition Of Primary Care
The committee's definition of primary care (see Chapter 2), which the committee formally recommends be adopted (see Box S-1), is presented in terms of the function of primary care, not solely in terms of who provides it. The definition calls attention to several attributes that provide the structure within which the broad themes of this report are addressed. The critical elements include
- integrated and accessible health care services;
- services provided by primary care clinicians—generally considered to be physicians, nurse practitioners, and physician assistants—but involving a broader array of individuals in a primary care team;
- accountability of clinicians and systems for quality of care, patient satisfaction, efficient use of resources, and ethical behavior;
- the majority of personal health care needs, which include physical, mental, emotional, and social concerns;
- a sustained partnership between patients and clinicians; and
- primary care in the context of family and community.
Value Of Primary Care
The committee's case for primary care (see Chapter 3) is made in two ways. The first concerns the value of primary care for individuals. The committee uses fictional scenarios to illustrate the terms in the definition and argues that primary care (a) provides a place to which patients can bring a wide range of health problems; (b) guides patients through the health system; (c) facilitates ongoing relationships between patients and clinicians within which patients participate in decisionmaking about their health and health care; (d) opens opportunities for disease prevention and health promotion as well as early detection of disease; and (e) builds bridges between personal health care and patients' families and communities.
The second way to approach the question of the value of primary care is by recourse to empirical evidence. The committee amasses considerable evidence that primary care improves the quality and efficiency of care and expands access to appropriate services; it also forms an important bridge between personal health care and public health, to the advantage of both.
The Nature Of Primary Care
The complexity of primary care is reflected in six core attributes explored in Chapter 4 of the report:
- Excellent primary care is grounded in both the biomedical and the social sciences.
- Clinical decisionmaking in primary care differs from that in specialty care.
- Primary care has at its core a sustained personal relationship between patient and clinician.
- Primary care does not consider mental health separately from physical health.
- Important opportunities to promote health and prevent disease are intrinsic to primary care practice.
- Primary care is information intensive.
In the committee's view, no health care system can be complete without primary care. In the United States, the time is right for primary care to undergo more systematic and creative development and to expand as the foundation of
health care delivery. It is amenable to improvement through methods of science, implementation of key supporting elements of the health care infrastructure, and use of relevant management and organizational principles. Much of the remainder of the report explores these points in more detail.
The Delivery Of Primary Care
The features of the U.S. health care scene that will influence the extent to which primary care evolves in this country are myriad: the spread of managed care, the expansion of integrated health care delivery systems, the consolidation of health plans and systems, growth in for-profit ownership of health plans and integrated delivery systems, the diversity among and within health care markets, the special challenges of primary care in rural areas and for the urban poor, the need for primary care to coordinate with other types of services, current and evolving roles for health care professionals, and the role of academic health centers in primary care delivery.
Key aspects of these trends and themes are explored in Chapter 5. Based on its analysis of these topics, the committee arrived at a series of recommendations concerning actions it believes would be necessary to overcome the barriers, or exploit the advantages, that these above factors pose for full implementation of the committee's vision of primary care. In all, the committee advances 11 separate recommendations in Chapter 5 (see Box S-1). The first group concerns the financing of primary care services, and the committee makes a strong statement about the availability of the services of a primary care clinician and the need for health care coverage for all Americans. Another recommendation concerns the organization of primary care and emphasizes the importance of the primary care team. With respect to underserved populations, the committee returned to its earlier themes to underscore the importance of primary care for populations who have special health care needs or who are traditionally underserved. Another major thesis of this chapter is the need for primary care to develop strong relationships with three other types of health activities—public health, mental health, and long-term care—and the committee offers three specific recommendations intended to reinforce the coordination and collaboration of efforts in these areas. Another recommendation calls for specific steps to develop tools and approaches for monitoring and improving the quality of primary care and to make performance information available to a wide audience. The final recommendation concerning the delivery of primary care calls on academic health centers to make primary care a core element of their mission and to provide leadership in education, research, and service delivery related to primary care.
The Primary Care Workforce
The committee concludes in Chapter 6 that the nation probably has a slight
shortage, overall, in supply of the principal types of primary care clinicians—physicians, nurse practitioners, and physician assistants—but it underscores the great difficulties of developing reliable and valid estimates of supply of and, especially, requirements for clinicians or clinicians' services. The committee states four recommendations concerning important directions for the production and use of primary care clinicians (see Box S-1). These involve: (1) continuing the current level of effort to increase the supply of primary care clinicians but ensuring that primary care training programs and delivery systems focus their efforts on improving the competency of primary care clinicians and on increasing access for populations not now receiving adequate primary care; (2) encouraging state and federal agencies to monitor carefully the supply of and requirements for primary care clinicians; (3) exploring ways in which managed care and integrated health care systems might be used to alleviate the geographic maldistribution of primary care clinicians; and (4) examining how state practice acts for nurse practitioners and physician assistants might be amended to eliminate outmoded restrictions on practices that currently impede efficient and effective functioning of primary care teams and access to needed health care.
Education And Training For Primary Care
If primary care is to move in the directions advocated by this committee, then many aspects of health professions education and training will need to be restructured. Chapter 7 explores the changes likely to be required in undergraduate and graduate training, argues that clinical training ought to involve multidisciplinary team practice, and examines issues of retraining physicians for primary care. The committee used the broad scope of primary care to suggest that all trainees should be equipped to practice competently in the following areas: periodic assessment of asymptomatic persons; screening and early disease detection; evaluation and management of acute illness; assessment and either management or referral of patients with more complex problems that call for the diagnostic and therapeutic tools of medical specialists and other professionals; ongoing management of patients with established chronic diseases; coordination of care among specialists; and provision of acute hospital and long-term care.
To reach this goal, the committee puts forward several recommendations (see Box S-1). With respect to undergraduate medical education, the committee is concerned about students gaining experience in primary care settings; with respect to graduate training, the committee explores issues of residency programs in family practice, internal medicine, and pediatrics. More broadly, the committee examines questions of advanced training for all primary care clinicians and calls attention to the need to develop a set of common core competencies for all primary care clinicians. In addition, the committee highlights its concerns about two special areas of emphasis—communication skills and cultural sensitivity. A major concern for the committee is financial support for primary care training,
and consistent with earlier recommendations about universal coverage for health care, the committee calls for an all-payer system to support health professions education and training, with some of this support reserved for primary care and directed to training in nonhospital sites such as offices, clinics, and extended care facilities. Other elements of education and training include developing more innovative and interdisciplinary training programs and creating mechanisms by which physicians can be formally retrained for primary care.
Research And Evaluation In Primary Care
Despite the committee's clear vision for the future of primary care and the consensus it reached on many steps toward bringing that vision to fruition, the committee still acknowledges that primary care represents a largely uncharted frontier awaiting discovery and exploration. Expanded research in this area is timely because of the accelerating movement toward a variety of managed care and integrated delivery systems, most of which will rely on primary care models and clinicians. To the degree that this is so, improved primary care that can bring about a better balance between patients' and populations' needs and the health care services they receive is critical.
As noted in Chapter 8, the science base for primary care is modest, and the infrastructure underlying the knowledge base is skeletal at best. Thus, the committee proposes four recommendations intended to strengthen the underpinnings of a primary care research enterprise (see Box S-1). These relate to (1) federal support for primary care research, including the designation of a lead agency in this effort; (2) development of a national database on primary care, ideally through some form of ongoing survey mechanism; (3) support of research through practice-based primary care research networks; and (4) development of standards for data collection, including attention to data element definition and improved coding.
The committee also identified a number of subjects that it believes warrant high priority in any primary care research agenda. Prominent among these is the committee's fifth recommendation in Chapter 8 concerning specialist provision of primary care. Other subjects involve major elements of the committee's conceptualization of primary care, such as the large majority of personal health care needs, the sustained partnership between clinicians and patients, accountability, and practicing in a family and community context.
A Strategy For Implementation
The recommendations described so far are regarded by the committee as essential steps toward strengthening primary care as the firm foundation for health care in this country, but only effective implementation will permit the nation to realize their benefits. To provide focus for the implementation effort,
Chapter 9 of the report discusses specific means for implementation and identifies the many parties whose commitment will be necessary. This plan for implementation is guided by several perspectives that, in the view of the committee, are essential for success: the need for a coordinated strategy, a long-term perspective, and involvement of a large set of change agents and interested parties.
Coordinated implementation by many participants over time is unlikely to take place unless an entity exists whose purposes are to build appropriate coalitions, stimulate action, and monitor and facilitate implementation. To this end, the committee recommends the formation of a public-private, nonprofit primary care consortium (see Box S-1). Its broad functions would be (among other things) to
- coordinate efforts to promote and enhance primary care;
- conduct research and development projects, provide technical assistance, and disseminate information on issues such as primary care infrastructure, innovative models of primary care, and methods to monitor primary care performance; and
- organize national meetings through which interested parties can report on progress in implementing the primary care agenda.
The committee's view of this entity as a public-private partnership was arrived at advisedly. Government at all levels has a deep interest in seeing the primary care vision of this committee succeed, but many aspects of the strategy proposed in this report require action and commitment by many entities in the private sector.
With the apparent demise of comprehensive national health care reform, the climate for moving ahead on a reform agenda affecting primary care might seem to be unfavorable. Yet, the pace of change in the health care systems of communities around the country remains very rapid. In those changes and the restructuring being proposed for Medicare and Medicaid, opportunities exist to make the American health care system more effective and efficient. Important parts of the agenda proposed in this report require federal action, but for many elements the key decisionmakers are to be found in the states and cities of this country, in health care plans, in educational institutions, in professions, and in private foundations. Many of these parties are already committed to a renewed emphasis on primary care. In this situation, opportunities for coalition building for implementation should be present, and that is one reason the committee has recommended establishment of a primary care consortium.
This is a time when creative effort and collaboration can influence the forces driving health care change in the directions defined by this committee. It will not be a time for weak hearts or quick fixes—but the promise of improving health care for Americans should be motivation enough to stay the course set out in this report.
BOX S-1 Committee Recommendations